Standardising and Optimising a Trial Without a Catheter (TWOC) in Older Male Inpatients: A Quality Improvement Project

Introduction   

Acute urinary retention is a common presentation in older male inpatients. Whilst urinary catheters are often necessary, they are associated with adverse outcomes, including catheter-associated urinary tract infections, prolonged hospital stays, and increased healthcare costs. At South Tyneside and Sunderland Foundation Trust, no local or national guidance existed to standardise trial without a catheter (TWOC). This quality improvement project (QIP) aimed to improve the assessment and management of urinary retention to standardise TWOC practice in older male inpatients.   

Method  

This QIP was conducted using the Plan-Do-Study-Act (PDSA) framework. A best practice standard for TWOC was developed with urology, outlining recommended assessment and management steps. Baseline data was collected retrospectively from male inpatients on two geriatric wards. Fifty patients were identified; seven were excluded, leaving 43 patients for analysis. Current clinical practice was compared against the agreed standard. Following analysis of baseline data, a clinical guideline was produced and implemented trust-wide, supported by targeted education for staff.  

Results  

32% of patients (14/43) were discharged with a catheter following an unsuccessful TWOC, of whom 64% (9/14) were discharged with a new long-term catheter. Seven patients were identified as being at risk of high-pressure chronic retention; none had documented urology input, and two underwent an inappropriate TWOC. Documentation of pre-TWOC assessment was inconsistent. A digital rectal examination was not documented in 76% (26/34) of patients assessed for urinary retention. Among patients suitable for medical management, 82% (9/11) were not commenced on an alpha-blocker during admission.   

Conclusion  

Significant variation existed in the assessment and management of urinary retention, with missed opportunities for optimisation before TWOC. Introduction of a standardised trust-wide guideline aims to improve clinical assessment, optimise medical management and reduce prolonged catheterisation. Re-audit will evaluate the impact of these interventions on clinical practice and patient outcomes.